In the September 1987 issue of the APSF Newsletter, "accident
analysis" was discussed by Dr. David M. Gaba. The summary of his work not
only addressed several factors that have been identified as increasing
accident rates in general as well as in anesthesia practice, but also provided
several reasons for system failures and/or accidents (for example, multiple
fail-safe mechanisms providing a false sense of security).

In 1985, MMI Companies, Inc., a professional liability
insurance carrier, recognizing the spiraling malpractice crisis, developed
an anesthesia risk modification program that focused on clinical practice
patterns which lend themselves to system failures, accidents, and potential
liability exposures. The program addressed systems, issues, and standards
in anesthesia practice.

The intent of the program was both to identify practice
patterns and change undesirable practices with the goal of improved patient
care and decreased liability exposure. In addition, the program was designed
to assist in developing an effective defense against allegations of negligence,
should an adverse outcome or patient injury occur.

Closed anesthesia claims were examined, and high liability
exposure practice patterns were identified. The frequency and severity
in terms of insurance pay-out were trended to determine the relationship
of the two. Severity was correlated to patient outcome. The claims review
revealed that more than 50% of dollars paid went to claims with the allegation
of "failure to monitor".

A further analysis of the "fa4ure to monitor" issues revealed
high exposure in all are-as of anesthesia practice, including:

* pre-anesthesia evaluation

* intra-op attendance and equipment to monitor patients

* post-anesthesia recovery and follow-up

Other allegations of significant frequency that were identified
are listed below in ranked descending order of severity:

* Improper administration of anesthesia"

* Intubation and IV related

* Improper positioning

* Equipment related

Following the claims review, a task force comprised of
practicing anesthesiologists from around the country was assembled. This
group provided input into the development of a risk modification program
to address the allegations identified in the claims review process.

One essential element of the program that the task force
identified was the need for leadership in anesthesia departments to provide
directions and facilitate change in warranted areas. It was felt that focused
leadership is critical to reducing claims in anesthesia.

The Anesthesia Risk Modification Program

The task force drafted guidelines which outline practices
that contribute to the effective management of liability exposures related
to the provision of anesthesia services. The guidelines address the responsibilities
of the Director or Chairperson of the Anesthesia Department, credentials
of anesthesia staff, anesthesia equipment, and patient care issues in pre-,
intra-, and post-anesthesia areas. They were designed to set minimum goals
that an anesthesia department would strive to achieve.

These guidelines form the foundation of a three part comprehensive
risk modification program developed to identify, monitor, and mitigate
risks associated with anesthesia practice. The three parts of the program
are designed to provide data on compliance with the guidelines, on-going
monitoring of statistics, and clinical case review.

1. Self Audit Questionnaire

The self audit questionnaire is completed by the Director
of the Anesthesia Department. It allows an assessment of the anesthesia
services compared to the program guidelines. The results of the self audit
assist risk management efforts to modify practice patterns that have been
identified as potential risks in the department. An annual review and repeat
of the self audit questionnaire allows the Risk Manager and Director of
the department to recognize change in the practice patterns of the department.

2. Statistical Data

An ongoing assessment of the department occurs through
the use of a criteria-based statistical form. This tool is comprised of
volume and outcome criteria that categorize department activities.

Volume statistics (e.g. general and conduction anesthetics
in out-patients vs. in-patients) provide the department with a means to
review staffing patterns, peak load times, and patterns in utilization.

Outcome indicators, such as deaths, cardiac arrest, neurological
or peripheral nerve injuries, etc., provide the Director of the department
with a snapshot view of the number of "serious patient outcomes" that have
a high potential for claim consequences. The patient outcome information
is collected on a monthly basis and submitted into a national data bank.
Again, the statistical information is designed to provide a mechanism for
liability-focused clinical risk modification, as opposed to a traditional
process-oriented quality assurance program.

3. Clinical Case Review

A mechanism was established to provide insight into cases
that meet a serious outcome criterion or had a higher degree of loss exposure
(increased potential severity). This step has become the most beneficial
and valued mechanism in the process.

Specific outcome indicators were identified for required
review by the departments involved. In general, required review is expected
in cases that resulted in actual or potentially liable situations and the
goal is to minimize both. For example, any time a cardiac arrest occurred,
the case was intensively reviewed. If the outcome was due to an anesthesia
related factor, a detailed in-depth review of the anesthetic occurs. This
system of clinical case review allows a follow-up mechanism that goes beyond
the mere numbers collected on a monthly basis in the statistical form.

The importance of the clinical case review rests on the
process and goal of the process. The key point of the review mechanism
is the focus on issues of safety in practice, not on discipline of practitioners.
Issues raised need to be addressed and resolved. Adverse trends identified
lead to changes intended to prevent future recurrences. The result of this
effort is improved patient care.

The clinical case review process allows the interaction
of people from the multiple disciplines involved with perioperative patient
care. The perioperative committee, therefore is comprised most often of
the Medical Director of Anesthesia, Medical Director of Surgery, Nursing

Managers of OR and PACU, CRNA, and the Risk Manager. This
committee functions as the anesthesia "risk management" committee. The
group works directly with the hospital risk manager to set into motion
activities to modify identified risk exposures.

Early Results

This approach to anesthesia risk modification has been
in operation for 18 months. While the program is very young, early results
are encouraging.

* The number of anesthesia departments instituting a perioperative
committee or an interdepartmental, interdisciplinary patient care committee
has increased considerably.

* Numerous hospitals have reworked the anesthesia record.
The clinical case review has prompted the supported positive changes in
these records because the review process needs a clear, detailed chronology
of events to work with.

* Some significant changes are occurring in equipment.
Departments are examining their old and outdated equipment and slating
it for replacement. Administrations are supporting these efforts since,
again, the emphasis is on reduction of exposure practices that may increase
insurance pay-out.

* A recent credit system was initiated for anesthesiologists
using pulse oximetry and capnography.

* One significant change is in departmental leadership.
Department he-ads have been assigned the additional responsibility of assuring
that all members of their departments are quality care providers, which
includes risk conscious practitioners.

In essence, the risk modification program described here
is a risk management program for the anesthesia department. A risk management
approach that is squarely set on prevention. Patient protection and consequent
protection of the anesthesia practitioner is its ultimate goal.

The ninth World Congress of Anesthesiologists will be
held in Washington, D.C. May 22-28. This meeting is co-sponsored by the
World Federation of Societies of Anesthesiologists and the ASA and is expected
to attract many practitioners from around the world. The theme of the

Congress is "vigilance".

There will be a refresher course given by APSF President
E.C. Pierce, M.D. on "State-of-the-art monitoring in anesthesia". Panels
with distinguished international participants will be held on "Anesthesia
patient safety" and "Anesthesia outcome and quality assurance. how do we
measure it and does it influence care?" In addition, there will be sessions
of scientific papers in the area of "Patient Safety and Risk Management."

Throughout the Congress, the Anesthesia Patient safety
Foundation will maintain a booth among the exhibits. In addition to general
information, there will be available bound volumes of the APSF Newsletter,
the videotape "Safety and Cost in Anesthesia," the "Spot the Error" videotapes,
and the APSF clipboards intended for 0. R. use. These clipboards have printed
on them an abbreviated anesthesia machine checklist and a relief exchange
protocol.

Also in the exhibits, a portion of the Ohmeda booth will
be continuously showing the ASA Patient Safety Videotape Series.

Congress registration information is available by calling
the ASA (312) 825-5586 or writing: 1'rS/WfSA;P.O.Box825;Deerfield,IL 60015.

There is also a pre-Congress meeting May 2 1 and 22 at
the Grand Hyatt Hotel at Washington Center sponsored by the Yale University
Department of Anesthesia. The meeting is entitled "Current concepts in
non-invasive monitoring and patient safety." Registration information can
be obtained by calling the Yale Office of Graduate and Continuing Education
(203) 785-4578.

In this issue, the first one of APSF's Newsletter Volume
3, it seems reasonable to reflect upon the first two years of the Foundation
and its future The mission remains the same to encourage activities that
will prevent patients from being harmed by anesthesia care. The Foundation
has been enthusiastically received in many quarters. Some, however, have
criticized us for being excessively oriented toward equipment monitors
and state-of-the-art anesthesia machines. The Foundation's Executive Committee,
indeed, encourages this criticism because it helps us to discover the directions
we should be taking. Honest differences of opinions always exist among
anesthesia clinicians.

Recently, I wrote the following to one of our supporters
who had voiced concerns; "The APSF continues to have as its only goal the
enhancement of safety in anesthesia. We have had to take this development
one step at a time and are indeed still feeling our way. I believe that
the first major approach was to try to cut the incidence of catastrophic
events, especially those which have been undoubtedly reduced by use of
oximetry and capnography. The Foundation has very strongly and studiously
avoided anything approaching the setting of standards or demanding that
certain equipment or machines be used. Rather, we have attempted to emphasize
safety through education and awareness' " I believe, in fact, that the
expenditure of Foundation funds so far has been primarily in areas not
benefiting industry although industry has provided the major financial
support thus far to the Foundation.

In my view, the two most important undertakings by the
Foundation have been the Research Grant Program and the APSF Newsletter.
Neither of these is equipment oriented. It is interesting to examine the
front page lead headline in some of the newsletters published thus far:
Leadership and Quality Care in Anesthetic Practice; FDA Issues Pre-use
Check-out; Anesthesia Claims Decrease; ASA Adopts Basic Monitoring Standards;
Support and Service Crucial to Safety; Better Labels Will Cut Drug Errors.

Efforts will continue to promote education in anesthesia
patient safety as the prime focus of the Foundation. Hopefully, the attempts
so far the research grants and newsletter noted above, the videotape and
book on Capnography, the videotape and book on Safety and Cost Containment
in Anesthesia, the videotape Spot the Error and the postponed Grand Anesthesia
Safety Symposium will be seen as true educational undertakings.

This year the Foundation will bring together several investigators
working on simulators and a number of anesthesia educators to explore the
potential use of simulators in anesthesia education and training, especially
in the management of the rare crisis situation. Strong efforts have been
made to eliminate any commercialism in this workshop.

The Foundation is funding a survey to assess national
and international work practices of anesthesiologists. A pilot study, already
completed, is to be expanded into a larger survey, reviewing the role of
fatigue and anesthesia patient safety.

Consideration of standards for anesthesia machines has
been an agenda item for the ASA Committee on Patient Safety and Risk Management
not the Anesthesia Patient Safety Foundation. The Foundation's Committee
on Education and Training, however, is planning a multi-disciplinary conference
to prepare a set of educational materials for describing current safety
features of the anesthesia machine and whether or not older machines can
be modified to include individual safety devices.

In the last issue, APSF circulated a questionnaire seeking
opinion of the readers concerning future safety symposium presentations.
We encourage participation by all of you who read the Newsletter in helping
the Executive Committee and Board to plan programs over the next two years.
Examine us, criticize us, write to us. Let us work together toward the
complete elimination of preventable anesthesia morbidity and mortality.

Although recent publications have strongly advocated the
use of monitors to reduce patient morbidity and mortality, there has been
difficulty achieving agreement on the level of monitoring which is desirable,
or which can be justified by economic constraints. A recent publication
by Whitcher, et all addresses this issue, and proposes a method of analysis
based on the cost of injuries, and the expected savings when monitoring
is used. It was presumed that 50% of the cost associated with insurance
premiums could be saved by using the recommended monitoring equipment.

The authors focused on preventable injuries. They drew
a careful distinction between injuries which are preventable, and injuries
which are due to an error in the legal sense; i.e. which fall below the
standard of due care established by legal means.

The results of these financial calculations are dramatic.
The savings of a 50% reduction in insurance costs are approximately $35,0001
operating room/year. The proposed monitoring standard costs approximately
$7,000/operating room/year, for a net savings of $28,000/operating room/year.

The costs of injuries was estimated using data provided
by the Saint Paul Fire and Marine Insurance Company, and referred publications.
In each case, the claims were associated with the administration of anesthesia.

The review of published studies of injuries associated
with anesthesia and the authors' experience suggest that it is conservatively
possible, with adequate monitoring, to avoid 50% of patient injuries using
current monitoring technology. The authors propose a monitoring standard
which, in their opinion, could achieve this savings.

While it was not possible to eliminate all assumptions,
it was possible to check most of the assumptions using several sources.
In additions, the results of this study were presented as a scientific
exhibit at two consecutive annual meetings of the American Society of Anesthesiologists
(ASA). Discussants included many of the cited authors, and many representative
physicians and manufacturers, as well as attorneys and representatives
of the insurance industry. No serious differences of interpretation were
encountered during this process.

Assumptions Critical

The critical assumption is that a 50% reduction in expense
would be achieved. The authors agree that this assertion is difficult to
prove. They note their own opinion, and that of the majority of authors
reviewing injury associated with anesthesia, supports this view.

There was a presumption that savings in insurance costs
would be passed through. It was argued that this is rational; the industry
is competitive, the costs are high enough to ensure comparison shopping,
and deductibles (particularly for the hospital) have risen high enough
to ensure a significant degree of pass-through. Evidence of insurance company
support for monitoring is cited.

Other aspects of the analysis appear conservative. The
calculated costs per operating room were based on the assumption of the
full-time practice of anesthesia; lower activity would increase the expense.
Savings could occur not only by identifying events in time to prevent injury,
but also in disproving claims or preventable events which did not occur.
Further, where several sources gave similar but differing values, the value
leading to the smaller saving was used.

The authors proposed the following monitoring equipment:
automatic sphygmomanometer, pulse oximeter, capnograph, spirorneter, halometer,
breathing circuit oxygen analyzer, stethoscope, ECG monitor, and thermometer.
This led to an estimated acquisition cost of $22,500 (see Table) or approximately
four times the estimated minimum cost of satisfying the ASA Standard for
Basic Monitoring approved in October, 1986.

In an accompanying editorial by one of the reviewers,
it was suggested that it is appropriate to spend up to the anticipated
savings associated with improved monitoring, given only that each monitor
added would further reduce the risk of injury. The editorial suggests an
enhanced list of monitors, acquires a more elaborate capnograph and pulse
oximeter, and additionally monitoring transcutaneous oxygen and carbon
dioxide, the neuromuscular twitch response to stimulation, continuous noninvasive
blood pressure, and continuous measurement of cardiac output. This further
enhancement in monitoring support led to a fourfold increase in expense
over that proposed by Whitcher, et al. However, the cost is still less
that the suggested savings in insurance expense.

One of the difficulties in this form of analysis is the
difficulty of designing a controlled study to evaluate the assumptions.
It is generally agreed that monitoring is highly desirable and seems likely
to reduce patient mortality/morbidity compared to the unmonitored state.
The American and Canadian Societies of Anesthesiologists have recommended
minimum standards. Thus, while the degree of safety afforded is difficult
to measure, the failure to monitor appears to increase the risk of injury
to the anesthetized patient. A controlled study to define the magnitude
of this risk seems hard to justify for the patient control group.

Proposed minimum standard for patient monitoring equipment
available during anesthesia

Equipment Cost

Pulse oximeter 5,500.00

Capnograph 4,600.00

Spirometer 1,000.00

Halorneter 3,5M.OO

Automatic sphygmomanometer 300.00

Breathing circuit oxygen analyzer 800.00

Stethoscope 50.0

Electrocardiogram 4,550.00

Thermometer 200.00

Total usual initial cost per room $22,500.00

If the appropriate study could be devised, it would also
be of great value to identify the order in which different monitors should
be added to the operating room to assure maximal reduction of risk, given
an inadequate monitoring budget. It could be argued that the marginal utility
(benefit) of adding one more monitor (e.g. the last on the recommended
list) would not exceed its cost. Whitcher et. al. argued otherwise, suggesting
that a minimally acceptable monitoring configuration should afford positive
identification of all major pathways to patient injury. (See figure)

It is worth nothing that this analysis focused on only
one form of cost insurance premiums and the associated deductibles. Injuries
seem to carry a significant economic and social price in other measures
as well, including the high incidence of physician suicide noted in one
careful study, and the effect on hospital and physician operating practices
in order to avoid claims.

While this analysis could not absolutely prove the authors'
assertion of savings, the weight of evidence seems to favor this conclusion.
How can one defend a failure to reduce operative morbidity and mortality
if the reduction is cost effective? Thus, there is a strong incentive to
either act on these conclusions, or to disprove them.

How safe is anesthesia now? How can anesthesia care be
made safer? Almost 25 million surgical operations are performed annually
in U.S. acute care hospitals, yet remarkably little is known about the
rates and causes of serious anesthesia-related complications. Thus, the
American Society of Anesthesiologists and the federal Centers for Disease
Control recently agreed to jointly support a pilot study during 1988 to
help plan a national study of mortality and severe morbidity associated
with anesthesia. The pilot study will not provide outcome data or test
hypotheses but rather will test and improve the proposed methodology for
the national study.

The national study seeks to learn how to improve the quality
of anesthesia care. Data will be collected in a representative sample of
hospitals and analyzed to estimate national and regional incidence rates
of anesthesia-related mortality and severe morbidity. The focus will he
factors having potential for preventive intervention: Anesthesia factors
such as technique and patient monitoring; patient factors such as the presence
of hypertension, obesity, and smoking; and hospital factors such as the
type of anesthesia provider and volume surgery.

All mortality and severe morbidity occurring within 48
hours of an anesthetic will be studied in patients undergoing inpatient
and outpatient surgery, cesarean section, and radiologic procedures. An
in-hospital investigator will collect detailed information which will be
reviewed in a blinded fashion by independent expert panels consisting of
two anesthesiologists and one surgeon. These panels will assess the contribution
of the anesthesia care to the adverse event. In addition, using other patients
at the same hospitals who (lid not suffer complications, a case-control
study will examine the anesthesia and personal factors that can affect
the occurrence of anesthetic-related adverse events. The analysis will
focus on anesthesia and patient variables, while controlling for such factors
as type of surgical procedure and the patient's age and ASA physical status
classification.

A pilot study is necessary to improve the protocol and,
in particular, to determine the feasibility of different aspects of what
is expected to be a three to five-year, multimillion-dollar study for which
governmental, industrial, and other private funding would be sought. It
is recognized that substantial scientific issues must be resolved and funding
obtained before such a large effort can be launched. The pilot study will
involve three months' data collection in five hospitals chosen so that
there is representation of a hospital with a medical school affiliation,
a community hospital with no medical school affiliation, and anesthesia
provided by nurse anesthetists.

This joint effort re-suits from more than I 8 months'
collaboration between Dr. Douglas N. Klaucke of the CDC's Division of Surveillance
and Epidemiologic Studies and the ASA Task Force on Morbidity and Mortality,
drawn from the Committee on Patient Safety and Risk Management, chaired
by Dr. Ellison C. Pierce, Jr. Task Force members are Drs. Jeffrey B. Cooper,
Stephanie M. Duberman, Fredrick K. Orkin, and Alan D. Sessler. For the
pilot study, the ASA will provide administrative support and anesthesia
consultation, the CDC will provide epidemiologic consultation, a blanket
of confidentiality over data, and oversight of the project. Battelle Human
Affairs Research Centers, a health care consulting firm, will collect the
data as a subcontractor. This collaboration is already being described
as a model for mutual cooperation between a medical society and a governmental
agency. Further information was presented in the February issue of the
ASA Newsletter and is available from Task Force members.

Dr. Orkin, University of California at San Francisco,
is a Task Force member and co-e6tor of Complications in Anesthesiology.

This is an interesting, and awe-some, 163-page report
(including 230 tables) of The Confidential Enquiry into Perioperative Deaths
(CEPOD), which summarizes the perioperative deaths occurring during a 12-month
period (I 1/85-10/86) in National Health Service hospitals in three regions
of Britain. A collaborative effort of the Association of Anesthetists and
the Association of Surgeons of Great Britain and Ireland, this undertaking
sought to determine ways to improve the delivery of surgical (including
anesthesia) cam As the most recent and one of the largest such study, it
represents an important addition to the literature on anesthetic related
adverse outcomes and risk management in our specialty.

The study design was rather simple-. voluntary, confidential
reporting of all deaths occurring within 30 days of surgery. The involved
anesthesiologist and surgeon completed separate, detailed questionnaires
which were "rendered anonymous" later destroyed). Blinded information on
each case was sent to consultants in surgery and anesthesia who evaluated
the appropriateness of surgery, adequacy of monitoring, quality of rare,
and avoidability of the death. The consultants were also asked for a judgment
on the contribution of the surgical condition, co-existing disease, anesthesia,
and/or surgery to the death.

The study directors set out to review 4034 deaths occurring
among more than half a million surgical procedures. (This gross mortality
rate, 0.7 percent, is less than expected.) However, they were able to obtain
information from both the surgeon and anesthesiologist for only 2391 deaths
(59.3%), suggesting that, even in a country with a much less litigious
atmosphere, voluntarism has severe limitations.

Consultants differed widely in their judgments: Surgeons
and anesthesiologists attributed only 0. I percent of the deaths solely
to an error in anesthesia management, and each discipline acknowledged
that some 20 percent of deaths were due to avoidable factors in its sphere
of activity. Interestingly, anesthesiologists felt that anesthesia and
surgery each contributed to 14 percent of deaths, whereas surgeons accepted
blame for 30 percent, leaving only 2 percent to anesthesia.

The most interesting, and sobering, results relate to
more global aspects of the surgical experience: As expected, 79 percent
of the deaths occurred in those over 65 years, whereas the elderly comprised
only 2 percent of the surgical population of these hospitals. Consultants
felt that the surgical disease caused a third of deaths and contributed
to two thirds; similarly, co-existing disease accounted for about one fifth
of deaths and contributed to one half. Overall, there was a strong suggestion
that much surgery had been undertaken inappropriately in moribund or terminally
ill patients who would not have benefited. The study also documented highly
variable supervision of surgical and anesthesia house staff, as well as
disturbingly high correlations of off-hours, unsupervised activity with
sicker patients and higher mortality. Using their own classification of
urgency of the surgery, the investigators also showed that few operations
must be performed at night.

Although many of their conclusions relate specifically
to the organization of surgical care delivery under the National Health
Service, there is much in this report that is of broad generic applicability
to the conduct of quality assurance and risk management programs. The report
may be obtained from the Nuffield Provincial Hospitals Trust (3 Prince
Albert Road, London NW I 7SP, England). A summary prepared by Drs. Lunn
and Devlin, as well as an editorial, appeared in 7he Lancet (2:1384-1386
and 1369-1371, respectively, 1987).

Abstracted by Fredrick K. Orkin, M.D., Department of Anesthesia,
University of California, San Francisco, School of Medicine.

Regarding the September editorial about anesthetists leaving
the O.R., the point struck home. I am one of 12 staff of a fully accredited
associate teaching hospital of the University of Calgary Medical School.
Early in 1987, some of the O.R. nurses got annoyed. They complained that
some of us were wandering about a little too much. They complained directly
to the hospital Patient Care Committee, sidestepping all normal channels.
This was very effective. Any anesthetist may be unaware of how "wandering"
can become a habit.

No hospital should be accredited if it has no monitors
and has otherwise inadequate equipment or if there is failure to use the
monitors or reasonably standard machines. Hospital administrations and
boards must be rapidly brought to a state of mind that requires all the
appropriate "goodies" and their use.

Our own battles are somewhat different. With anesthesia
machines getting more and more complex and expensive, it means a huge replacement
cost once a decade or sooner. Our next bill will come to half a million
dollars just for machines and, in addition, the whole hospital (O.R., Recovery,
I.C.U.) is going to have oximeters.

Videotapes # 1 0 and #II in the ASA Patient Safety series
were taped in December and January. John 1. Savarese, M.D. was the producer
of "Safety in Neuromuscular Blockade," which was prepared by Park Row at
the Massachusetts General Hospital and funded by Burroughs-Wellcome. Bernard
V. Wetchler, M.D. was producer of "Safety in the Post Anesthesia Care Unit".
The videotape was funded by ASA and an educational grant from Datascope.
It was prepared by the FDA at the University of Florida, Gainesville.

For Anesthesia Departments in United States hospitals
of more than I 00 beds, the entire series is available free through the
Burroughs-Wellcome Company. Interested departments that have not already
been placed on the mailing list may do so by contacting the local Burroughs-Wellcome
representative.

The series will be available for purchase by Anesthesia
Departments outside the United States at the Anesthesia Patient Safety
Foundation Booth during the Ninth World Congress Meeting in

It should be noted that at least one malpractice insurance
company in the United States has allowed a reduction in anesthesia malpractice
premiums for anesthesiologists who view the videotapes annually.

The authors of this interesting paper reviewed some 900
cases compiled by the American Society of Anesthesiologists Committee on
Professional Liability during its nationwide study of closed insurance
claims from major anesthetic mishaps. The authors describe 14 cases of
intraoperative cardiac arrests during spinal anesthesia in otherwise healthy
patients. They maintain that each mishap occurred for less than obvious
reasons, and may represent a "sentinel event: an unusual or unexpected
outcome that should not occur under the prevailing conditions of health
care." These cases thus provided an opportunity for a detailed analysis
that might "reveal recurring patterns of clinical management that contributed
either to occurrence or outcome".

Citing the "almost irresistible tendency to assume that
overt negligence has played an important contributory role [in an anesthetic
catastrophe]", the authors were struck by "the overall adequacy of basic
anesthetic care" in these cases. The patients were selected for spinal
by experienced clinicians, the amount of supplemental sedation did not
appear to be excessive, and intraoperative vigilance appeared to be adequate.
The highest spinal level was T4' The average time between the last verification
of adequate circulation and ventilation and the first indication of problems
was only 1.6 minutes. The average time between the first indication of
inadequate circulation or ventilation and the onset of cardiopulmonary
resuscitation was also only 1.6 minutes. In spite of prompt resuscitation
efforts, six patients died in the hospital and another seven suffered severe
neurologic dysfunction.

The authors were able to identify two management patterns
which correlated with these poor outcomes. The first was the use of "sufficient
sedation to produce a comfortable appearing, sleep like state in which
there was no spontaneous verbalization". This occurred in seven of the
patients, and in six of these cyanosis was noted prior to the cardiac arrest.
Thus, the possibility of respiratory insufficiency as the precipitant of
cardiac arrest was raised for in approximately half of the patients.

A second pattern involved the conduct of CPR. The average
duration of CPR was eight to ten minutes; ephedrine and atropine were given
early during the resuscitations, but epinephrine was not given until about
five minutes after the initiation of CPR, and, on the average, about seven
and one half minutes after the first clue of hemodynamic compromise. The
authors suggest that the presence of high spinal anesthesia with concomitant
sympathectomy, and hence relative intravascular hypovolemia and bradycardia,
may have explained the difficulty of successfully resuscitating these patients
after the onset of cardiac arrest.

In concluding, the authors reiterate that these cases
represent cardiac arrests which "seemed to evolve with unexpected speed
against the background of apparently stable hemodynamics." They point out
that they cannot fully understand this based on the data, nor can they
determine the incidence of such occurrences, but "wish to emphasize that
spinal anesthesia-conducted under routine conditions and in a standard
manner-carries a poorly understood potential for sudden cardiac arrest
and severe brain injury in healthy patients".

They offer three suggestions for anesthetic care based
on their findings: First, the use of a pulse oximeter for sedated patients;
second, the use of epinephrine "early in the treatment of sudden bradycardia";
and third, "a full resuscitation dose of epinephrine. . immediately upon
the recognition of cardiac arrest".

Dr. Arthur Keats, in an accompanying editorial, praises
the efforts of the University of Washington team and enlarges the discussion
of possible mechanisms for cardiac arrest and inadequate resuscitation
of these patients. Caplan and his coworkers have clearly provided a valuable
lesson in analysis of this uncommon type of anesthetic mishap.

The APSF is currently examining what clinical I anesthesia
simulators could contribute to the training and education of anesthesiologists
and nurse anesthetists.

A number of investigators have developed simulators that
can be used to demonstrate the pharmacokinetics of drugs, the responses
of patients to anesthesia, the workings of an anesthesia machine, and the
meanings of variables reported by monitors, to name a few.

These simulators allow the trainee to "play a scenario"
without threatening the safety of the patient and to explore what would
happen if an adverse process were allowed to go unchecked. Of course, simulators
are widely and successfully used in many other are-as. Best known are the
flight simulators employed by all major airlines and the Air Force. These
simulators are wonders of technology. Even though they are enormously expensive,
(one flight simulator may cost $ 1 0,000,000), the aviation industry has
found them to be cost effective. Other users of simulators (including the
Navy and the atomic energy industry) concur.

The Foundation raised the question: What can simulators
do for us in anesthesia? Will they be simply research toys for a few computer
wizards or can they really play an important part in the training and education
of clinical personnel?

In September of 1988, the Foundation will bring together
a group of educators in anesthesia and the designers of several simulators
to answer that question. The educators will have an opportunity to examine
and test the simulators (or be tested by them) and explore how these devices
might fit into the educational curriculum of trainees as well as programs
for continuing education. Once we understand the role simulators might
play in our specialty, we can ask the question whether these newcomers
to medicine will be cost-effective.

Dr. Gavenstein, University of Florida, Gainesville, is
a member of the APSF Executive Committee.

The current ASA standards for temperature monitoring state
that "When changes in body temperature are intended, anticipated, or suspected
the temperature shall be measured. " I have recently been apprised of a
caw of Malignant Hyperthermia that was noted late in the course of the
syndrome. By the time suspicion of MH had be-en raised and temperature
monitoring was secured, the rectal temperature was well over 102 ' F. Other
metabolic changes ensued which eventually lead to the demise of the patient.

I have also been involved in consultations on several
legal cases involving Malignant Hyperthermia. In at least one of them,
a verdict was rendered against the defendant anesthesiologist in large
part because the anesthesiologist failed to continuously monitor the patient's
temperature. Reasons commonly given for not continuously monitoring temperature
include lack of availability of equipment, inconvenience of placing temperature
probes, and possible patient injury from temperature probe placement. All
of these excuses are invalid. Temperature monitoring devices are relatively
inexpensive. Probes can be placed in the axilla, in the pharynx or in the
esophagus and indicate, at the least, temperature trending.

Another reason for failing to monitor temperature, is
that fever is said to be a late sign of Malignant Hyperthermia. Although
true in general, in specific cases, temperature elevations may occur early
in the course of MH.

Furthermore, temperature monitoring detects hypothermia
which may result in patient morbidity, especially in children.

I therefore believe that the Anesthesia Patient Safety
Foundation should urge the American Society of Anesthesiologists to change
the standards of intraoperative monitoring to include continuous body temperature
monitoring for all patients receiving general anesthesia. I contend that
body temperature changes can be anticipated in any surgical patient undergoing
general anesthesia and should be measured. Medico-legal considerations
and quality care demand nothing less.

Many ASA members have expressed some confusion as to how
they can apply for or renew membership in the Anesthesia Patient Safety
Foundation (APSF) in light of the statement approved by the ASA House of
Delegates encouraging ASA members to become dues paying members of APSF.

There is a simple procedure for ASA members to apply/renew
their membership donation to the APSF. The Annual ASA Dues Statement contains
a section which enables an ASA member to check-off his/her annual membership
donation to Patient Safety and include it with the ASA dues payment. This
method insures continuation of your existing APSF membership or establishes
a new membership in your name if you have not joined previously.

The ASA dues statement shows Patient Safety with a pre-printed
$2 5. 00 contribution amount. While we would like every ASA member to be
at least a $25.00 member of APSF, we have found many ASA members have supported
APSF with a larger donation, such as those Groups organized as Professional
Corporations (P.C.), which contribute the Corporate Member donation of
$500.00. To encourage this level of support,

ASA members wanting to make a larger donation need only
to cross-out the pre-printed $25.00 contribution and enter next to it the
amount of their donation.

Through the dues check-off mechanism, ASA members can
assure their membership and annual support of APSF. However, if you have
already paid your 1988 ASA dues but did not check off a contribution to
APSF, you can still support the Foundation by filling out an APSF member
application and returning it with your member donation. Copies of the application
can be obtained by calling the APSF office at (312) 825-5586.

"Anesthesia Systems" is the title of the January, 1988
issue (Vol. 17, No. 1) of Health Devices published by ECRI in Pennsylvania.
This extensive evaluation of anesthesia machines, including the newest
Drager and Ohmeda models, and related equipment contains brand name and
model specific ratings and listings of advantages and disadvantages of
the various systems. Further, there are detailed suggestions on how to
choose an anesthesia system to meet individual needs.

Under the heading "Evaluation: anesthesia systems" are
included sections on the Penion AM 1,000, new models and changes, and on
automated record keeping in anesthesia.

Health Devices is a hospital-oriented publication available
by subscription. Single copies such as this issue on anesthesia systems
are $50.00. For more information, contact ECRI, 5200 Butler Pike, Plymouth
Meeting, PA 19462, (215) 835-6000.

The Anesthesia Patient Safety Foundation Newsletter
is the official publication of the nonprofit Anesthesia
Patient Safety Foundation and is published quarterly in March, June, September,
and December at Overland Park, Kansas. Annual membership: Individual $25.00,
Corporate $500.00. This and any additional contributions to the Foundation
are tax deductible @Copyright, Anesthesia Patient Safety Foundation, 1988.

The opinions expressed in this newsletter are not necessarily
those of the Anesthesia Patient Safety Foundation or its members or board
of directors.